Pre-Assessment Quiz

A nurse is planning on teaching a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching?

After the procedure you will be encouraged to drink plenty of fluids The nurse should encourage fluid intake after the procedure to help promote elimination of the dye used during the procedure.

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

Agitation The nurse should expect agitation due to neurological changes from poor oxygen exchange.

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?

As soon as the nurse can prepare the client and the administration set. The nurse should infuse the blood as soon as possible and complete the procedure within 4 hr.

A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first?

Auscultate for wheezing When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respiratory status. Bronchoconstriction or closure of the upper airway may occur, which places the client at risk for respiratory arrest.

A nurse is teaching a client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. Which of the following foods should the nurse advise the client to increase in her diet?

Broccoli Broccoli is high in calcium. Most vegetables contain considerably less calcium, except for kale, collard greens with stems, and turnip greens, which are also good sources of calcium.

A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid.

Chocolate The client should avoid foods that reduce pressure on the lower esophageal sphincter. These include fatty and fried foods, chocolate, caffeine, alcohol, and carbonated drinks.

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?

Clients who have COPD use accessory muscles to assist with respiratory effort. The use of those accessory muscles causes the chest wall to eventually increase in anterior-posterior diameter, making it appear barrel shaped.

A nurse is assessing a client who is in a body cast. Which of the following manifestations should the nurse identify as possible cast syndrome?

Dilated pupils Cast syndrome is a reaction to wearing a large cast, which produces physical and psychological effects on the client, similar to claustrophobia. Cast syndrome can lead to paralytic ileus, or gangrenous bowel. The nurse should expect the client to exhibit diaphoresis, increased respiratory rate, and anxiety as manifestations of cast syndrome.

A nurse is teaching a client following a cystoscopy about his new prescription for tamsulosin. Which of the following effects should the nurse include in the teaching?

Dizziness Lightheadedness or dizziness is likely with the first several doses. Clients should be taught to rise slowly and carefully from lying or sitting positions until the sensation disappears.

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?

Gallstones The client's history might reveal biliary obstruction from a gallstone causing bile to inflame the pancreas.

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Hacking cough A hacking cough is a manifestation of left-sided heart failure that occurs due to pulmonary congestion.

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?

Hematemesis When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority finding is hematemesis, which indicates massive bleeding.

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse take?

Hypovolemia A low CVP indicates reduced right ventricular preload, which can be seen in clients who are experiencing hypovolemia, excessive blood loss, or overdiuresis.

A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side. (Selectable areas, or "Hot Spots", are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

Left dorsalis pedis (Left top of foot) The most distal pulse refers to the pulse that is at the farthest point on the affected extremity. The dorsalis pedis pulse on the anterior foot is the most distal pulse below the femoral artery. Because the client had left-sided angiography, the correct answer will be the left pedal pulse.

A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?

Leg pain at rest In the initial stages of PAD, clients might experience intermittent claudication. As the disease progresses, the client will experience pain even at rest due to ischemia of the distal extremities. The client might describe this pain as a persistent burning or aching pain that often awakens the client at night.

A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? SATA Loss of color discrimination Moon face Coarse facial features Enlarged distal extremities Hepatomegaly

Loss of color discrimination Moon face Coarse facial features Enlarged distal extremities Acromegaly is a chronic metabolic disorder caused by an excess of growth hormone (hyperpituitarism) during adulthood, after normal growth of the skeleton and other organs is complete. Often rising from an adenoma, the tumor compresses the optic nerve and causes visual changes such as loss of color discrimination, narrowed perceptual field, or blindness.

A nurse is caring for a 73-year-old client in the emergency department (ED). It has been identified that he client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications? Obtain a wound culture Measure lactate level Insert a nasogastric (NG) tube Obtain blood cultures Rapidly administer 30mL/kg of normal saline Type and cross-match for 2 units of packed RBCs Administer broad-spectrum antibiotics Obtain a urine specimen

Measure lactate level Rapid administration of 30mL/kg of normal saline Obtain blood cultures Administer broad-spectrum antibiotics Measure lactate w/n first hour after onset manifestations to identify severity. Start rapid administration of crystalloid w/n the first hour after onset manifestations (like hypotension or lactate >/= 4mmol/L). Blood cultures should be obtained before administering antibiotics to identify the specific microorganism. Broad-spectrum antibiotics assists in eliminating the micro-organism until the specific organism is identified.

A nurse is preparing educational material for a client who has a thrombocytopenic disorder. Which of the following information should the nurse include?

Notify the dentist of your condition prior to invasive procedures. The client is at high risk for bleeding; therefore, the client should avoid dental work if possible, especially tooth extraction. If the client must have dental work, the dentist should be aware to decrease the risk of bleeding and to hold pressure for longer time frames if bleeding occurs.

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

Place suction equipment at the client's bedside Cranial nerves IX (glossopharyngeal) and X (vagus) innervate the muscles of the soft palate, larynx, and pharynx. Impairment of these nerves places the client at risk for aspiration, making it necessary for the nurse to have access to suction for the client.

A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?

Place the client on his left side in Trendelenburg position. This position helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle and move to the pulmonary arterial system.

A nurse in a clinic is teaching information about cervical polyps with a client who has a new diagnosis. Which of the following information should the nurse include in the teaching?

Postcoital bleeding may occur. The client may experience bleeding, because the polyps are soft, fragile, and bleed when touched.

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider?

Presence of peripheral edema The client who has SLE is at greatest risk for death from lupus nephritis. Therefore, according to the safety and risk reduction priority setting framework, findings that indicate an impairment of renal function are the highest priority to report.

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take first?

Reposition the client The nurse repositioning the client is an appropriate action to relieve chest burning from the chest tube.

A nurse is caring for a client who has sever right wrist pain. The nurse has completed the assessment of the client. Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing ___ and ___.

Respiratory acidosis Hypovolemia An adverse reaction to morphine sulfate is respiratory depression. The client's respiratory rate has has decreased from 20/min to 10/min and is now shallow. Respiratory acidosis occurs when there is impaired respiratory function, causing reduced oxygen and carbon dioxide exchange, which leads to carbon dioxide retention. The client is at risk for hypovolemia because of their history of congestive heart failure and the rate at which the IV solution is running.

A nurse is discussing Russell's traction with a newly licensed nurse. Which of the following statements about this form of traction should the nurse include in the teaching?

Russell's traction uses a sling under the knee to treat a fracture of the femur. Russell's traction is a type of skin traction that incorporates a sling under the knee that is connected by a rope to an overhead bar pulley.

A nurse is caring for a client who is postoperative following a right-sided mastectomy and has a drain connected to a portable drainage evacuator. Which of the following actions should the nurse take?

Take blood pressures on the client's non-affected arm The nurse should plan to only take blood pressures, give injections, or perform venipuncture on the client's non-affected arm to avoid compromising circulation. The nurse should instruct other staff to follow these precautions as well.

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens his eyes when spoken to A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain.

A nurse is teaching a client who is preoperative for a colectomy. The client asks the nurse why he needs a large-bore NG tube. Which of the following statements should the nurse make?

The tube will remove gas and fluid from your stomach. Will decompress the stomach of gas and fluid in order to allow the bowel to rest.

A nurse is caring for a client who is scheduled for an arthroplasty. The nurse asks client to state if he understands the procedure that is being performed. Which of the following statements by the client indicates an understanding for the procedure?

This procedure will replace my joint to improve function. Arthroplasty is the reconstruction of replacement of a joint. This procedure is done to relieve pain, improve or maintain range of motion, and correct the present deformity.

A nurse is admitting a client from a provider's office. Click to highlight the provider prescriptions the nurse should implement first. VS on admission and q4hr NPO CBC BMP ABG Hemoccult stool Stool culture and sensitivity Urin culture and sensitivity Sitz baths up to 3 times daily PRN Meds: Dextrose 5% in 0.45% NaCl IV at 125mL/hr Metoclopramide 10 mg IV q6hr PRN nausea/vomiting Ciprofloaxacin 400 mg IV q12hr

VS on admission and q4h Stool culture and sensitivity Urine culture and sensitivity Dextrose 5% in 0.45% NaCl IV at 125 mL/hr It's important for the nurse to establish baseline VS to monitor the progression of the client's plan of care. Specimens (both urine and stool) should be collected for culture and sensitivity prior to initiating anti-infective therapy. The client is experiencing hypotension and fluid volume deficit related to vomiting and diarrhea. It is important for the nurse to initiate fluid resuscitation therapy to prevent further decompensation of the client.